Let’s work together Name * First Name Last Name Email * Phone * (###) ### #### Your child's age? (If more than one please include the age of each child) * Your child's full name (if more than one - please include the names of all children) * What services are you interested in? * Newborn Consultation Infant & Early Toddler Support Package Toddler Support Package Ask Me Anything Personalized Sleep Plan Only Do you have a spouse or partner? If so, will they be involved in the sleep training process? Please share their name: * What is your child's current daytime sleep schedule (if any)? * What does your child's bedtime routine look like? * What does your child wear at bedtime? * Examples: swaddle, sleep sack, footed sleeper/pajamas, etc. What does your child's sleeping arrangement look like? Please be specific: * Please describe, in as much details as you can, the environment in which your child sleeps. Examples: in their own room, in a room shared with a sibling, in a crib/swing/bassinet, blackout shades on the window, mobile over crib, sound machine, etc. How many hours does your child sleep in a 24-hour period? * What are your child care arrangements? * Home with a parent Home with a nanny Daycare Other Does your child use a pacifier to sleep? * Yes, and I often have to replace it through the night Yes, but it is not a sleep prop (e.g. my child doesn't mind if it falls out) No Does your child use any sleep props to fall asleep? * You may select more than one Nursing to sleep Bottle to sleep Rocking to sleep Bouncing, swaying, or any other movement My child doesn't use any props to fall asleep at bedtime or through the night Wanting a parent to sit in the room while they fall asleep Wanting a parent to lie in bed with them while they fall asleep Other Is your child breastfed or bottle fed? If your child is weaned from the breast or bottle, please put N/A. Is your child being fed in the middle of the night? If so, please explain how much or how often. If your child is over the age of two, how much screen time is allowed? Which best describes your child's personality? You may select more than one. Quiet, mellow, laid-back, doesn't mind change Cranky, fussy, rarely in a happy mood Clingy, anxious, often experiences separation anxiety Strong-willed, stubborn, resists change Happy, playful, usually in great spirits Have you tried any other sleep programs or methods to get your child to sleep better? Which best describes how you feel about crying? I don't mind hearing crying I don't mind hearing some crying I cannot stand to hear any crying What developmental milestones (if any) has your child accomplished? * Click all that apply None yet Holding head up when placed on belly Rolling onto side Rolling from belly to back Sitting, but cannot like back down Crawling Standing, but cannot sit back down Walking Please provide, in detail, any additional information that will help me understand what's going on with your child's sleep. If you have specific questions you can include them here. Thank you!
